Exclusive: New CDC Data May Not Show Risk Due To Metzitzah B’peh

The Centers for Disease Control, an agency of the US Department of Health and Human Services, just published a report stating that the risk for herpes simplex virus type 1 (HSV-1) following circumcision with oral suction, or metzitzah b’peh (mbp), was over 3 times greater than among male infants who did not have mbp. However, a closer examination of the data and methodology set forth in the report could point to a contrary conclusion – the risk of HSV-1 with or without mbp may be statistically the same. If so, the demonization of mbp caused by this report may lead public health officials away from addressing some real – and avoidable – causes of neonatal HSV-1.

The report, published in the June 8th issue of the CDC’s MMWR newsletter, looked at cases of HSV-1 in NYC dating from April 2006, when the disease became mandatorily reportable by hospitals, healthcare providers and clinical laboratories, through December 2011. It found 5 cases of HSV-1 after mbp during that time period, out of an estimated 20,493 mbp circumcisions (or 1 in 4,099). This rate, it said, was 3.4 times greater than that found in the City’s general population. CDC editors commend the report’s findings as “consistent with a cause-and-effect relationship” between mbp and neonatal HSV-1. Asserting that the data “strongly suggest HSV-1 can be transmitted to a neonate” by mbp, the CDC is encouraging “preventive” public-health tactics and, if necessary, even “legal measures” to ensure “that parents can choose not to have their newborn exposed” to HSV-1 through mbp.

Such alarming conclusions about a millennia-old religious practice have rightfully occasioned concern in the public-health arena as well as in the Jewish community, warranting a second look at the terms of the study. This further review exposes several troubling weaknesses, a few of which follow.

The data. In order to connect neonatal HSV-1 with mbp, researchers looked for cases of HSV-1 that had onset of symptoms as much as 20 days post-circumcision. Yet the universally accepted view is that HSV-1 has an incubation period of 2 to 12 days from exposure. Limiting the incubation period to 12 days – or even extending the limit up to 19 days – would decrease the number of cases in the report by 20%, bringing the HSV/mbp rate down to 1 in 5,123.

Methodology. Researchers drove their rate higher by including an unspecified number of cases from Jewish families that were not ultra-Orthodox in its estimate of “relative risk.” We learn in an editorial note that “the findings in this report are subject to at least one limitation. . . . not all of the cases were in ultra-Orthodox Jewish families.” This means that the study estimated the relative rate of incidence of HSV-1 in NYC using a formula that had as its “denominator” an estimated population of ultra-Orthodox Jewish males, but its “numerator” – actual cases of neonatal HSV-1 – included an unspecified number of cases from outside its “denominator” population.

As the editors explicitly note on this point, “”relative risk depends, in part, on assumptions . . . and those assumptions might not be valid.” Correcting for this arbitrary skewing of the formula could drastically reduce the rate of HSV-1 after mbp, perhaps to a rate even less than that of the general population. (One clear counter-example to the report’s findings is the community of Kiryas Joel in Orange County, which has an estimated 100% rate of mbp and 0 reported cases of associated HSV-1.)

Omission. Another significant weakness in the report is that it fails to cite even a single case where mbp was definitively determined to be the cause of HSV-1, for example by DNA testing. Some attempts were made to definitively link mbp to HSV-1, but the report relates that they were unsuccessful. In fact, despite the heightened focus on mbp and despite mandatory reporting of neonatal HSV-1, no definitive case of mbp-caused neonatal HSV-1 exists anywhere in the medical literature. Without any such case, the most the editors can say is that the data “are consistent with” or “strongly suggest” a correlation to mbp.

On the other hand, the new data could actually prove a contrary conclusion – that mbp poses no statistically greater risk of HSV-1.

Correcting for the overextended incubation period and/or faulty population figures, the report’s findings of HSV-1 incidence after mbp would be statistically equivalent to the rate found nationally. The national rate, as stated in medical literature, is anywhere from 1 in 1500 to 1 in 3200. This rate can be influenced by factors such as living in a metropolitan area and family size – dense areas and big families tend to have higher rates. Considering that NYC ultra-Orthodox Jews have large families and live in the most densely populated US city, neonatal HSV should occur closer to the higher (1/1500) rate. This rate, though, includes both HSV-1 and HSV-2, and HSV-2 has never been associated with mbp. Even assuming a 2:1 to 3:1 ratio of HSV-2 to HSV-1, the resulting rate of HSV-1 would be 1/4500 to 1/6000, right in line with the report’s data as corrected. (Indeed, it is curious that the report estimated the rate of incidence in the general NYC population to be much lower than the presumed national rate. Is neonatal HSV-1 that much rarer in NYC than elsewhere in the country?)

Even without adjusting for incubation period or population, the report finds the same rate– one HSV-1 case per year – both before and after neonatal HSV-1 became reportable in 2006. (In fact, right-sizing the incubation period would make the rate lower after HSV-1 reporting was mandated.) This is quite significant, as one of the reasons neonatal HSV-1 was made reportable in NYC stemmed from a suspicion that cases occurring after mbp were somehow hidden, and thus that the actual incidence was much higher than previously known.

Ultimately, focusing on mbp as a mode of transmission for HSV-1 may have the effect of ignoring other routes known to transmit the virus, with potentially tragic consequences. It is well established that HSV-1 is much more easily transmitted by symptomatic individuals than by asymptomatic “shedders.” No practitioner of mbp has been shown to be symptomatic, so those presuming mbp to transmit HSV-1 assume practitioners are shedders. And yet, as the report mentions, attempts to find such shedding in mbp practitioners have failed. Moreover, one case known to be included in this report involved a newborn in close contact with a symptomatic sibling who had recurring outbreaks of active herpes lesions. This was known to the attending physicians, and thus, we assume, to the researchers. Yet this fact was apparently ignored, and focus instead was trained on mbp. Nor were any follow-up attempts made to educate parents about the dangers posed by symptomatic individuals – whether they be siblings, caregivers, or the parents themselves – having contact with newborns. One has to wonder if the single-minded focus on mbp might itself be a public health issue, allowing for a much more common danger – one widely known to have serious, even fatal, outcomes.

In its Notice of Public Hearing in early 2006, the NYC Department of Health and Mental Hygiene (headed at the time by the current director of the CDC) wrote: “Making neonatal herpes reportable would ensure that such instances [of neonatal HSV-1 after mbp] are reported, and thus enable the Department to identify outbreaks of this disease in a timely fashion, identify the source, and intervene to prevent subsequent cases.” Ironically, this new CDC report may finally quash the suspicion of underreporting, and thus belie the notion that mbp is the public health issue concerning neonatal herpes that officials need to address.

Mr. Simins’ point under “Methodology” misinterprets the ‘limitation’ in the data described in the report. The inherent limitation in the data is that the CDC assumed 100% of ultra-orthodox (Hassidic) infants and 50% of yeshiva (referred to alternatively in the report as: kindergartners in Jewish day schools, Yeshiva schools and Jewish day schools) infants underwent a milah accompanied by MBP. It is impossible to know definitively whether the 100% or 50% numbers are accurate – the report does not tell us what constitutes an ultra-orthodox school (is it truly only chassidic schools) or a Yeshiva (some Yeshivas are day schools while others are comprised of students from families that are clearly ultra-orthodox and would have had milah performed with MBP). The denominator would be smaller if either the 100% or 50% were overestimated (and the rate of 3.4 would go up) and would be larger if the 50% number was an underestimate (and the 3.4 rate would go down). These estimates are not a skew or arbitrary but as good a guess as one can make (I personally would guesstimate that the 50% number is too high a number since by 2006 many mohalim in NYC were wary and refused to do MBP in many communities even for yeshivaleit). What is clearer though is that the 5 instances of HSV-1 were by definition within the denominator group (those assumed to have had MBP performed), i.e., 2 of the 5 were confirmed to have had MBP and 3 were ‘probable’ = parents would not directly answer questions about whether MBP occurred, but usually stated that all male infants in their community would be expected to have had direct orogenital suction. Those 3 instances were not as Mr. Simins suggests: “cases from outside its denominator population” – while they were not ultra orthodox (hassidic), the ‘probable’ finding places them squarely within the segment of the Yeshiva group that very likely did have milah performed with MBP (more like korov lvadai then raglayim ledovor

Thank you Rabbi Simins for having the courage to state the truth. We need more such people who will expose the Health Dept.’s agenda for what it is.
We Torah Yidden will rally around the ehrliche, good people who stand up for the truth.
Rabbi Simins, yeyasher koach.

“New CDC Data May Not Show Risk Due To Metzitzah Bpeh”
As I worked with Rabbi Nisson Wolpin of The Jewish Observer for many years, I feel your headline is ambiguous at best, and possibly, wrong.
Based on the article, the headline should be changed to:
“New CDC Data and Conclusions vs. MBP are Inconclusive and Possibly Wrong”

Mr. Simmins is technically correct when he says that “no definitive case of mbp-caused neonatal HSV-1 exists anywhere in the medical literature.”

However, it is worth pointing out the context:

In no case has a mohel suspected of HIV transmission allowed investigators the opportunity to check his DNA against that of the infected child’s virus.

I shall not speculate as to the reason why the suspected mohelim refused to submit to DNA sampling under standard forensic protocols (cheek swab in the presence of investigators), but it is highly disingenuous to trumpet that “No DNA Link Has Ever Been Established!” while ignoring the reason, which is that no suspected mohel has agreed to provide DNA.

Excellent article! I recently read another article on this topic at Jlaw.com that points out some other signifigant flaws in the studies as well.

1) Tests for HSV-1 anti-bodies are inconclusive because 90% plus of adults have been exposed to the virus at some point and thus will test positive anti-bodies present.
In each of the above alleged cases, not one single mohel was ever tested to see if they had ACTIVE HSV-1. It is ONLY when active that transmission is possible (“shedding”). By the way, in one alleged case the mohel tested NEGATIVE on the anti-body test!

2) There has never been a DNA test done to determine if the HSV-1 found in any of these children matched that of the mohel alleged to have transmitted the virus to them.

Testing for active virus and DNA matching are STANDARD protocol in epedemiology. Without BOTH of these tests (let alone even EITHER of them), it is IMPOSSIBLE to conclude that person “A” transmitted the virus to person “B.”

That these studies are so far outside normative practice and, therefor, nothing more than sloppy, non-scientific conjecture leads one to the inescapable conclusion that there is something else going on here other than “the interests of public health.”

excellent article ,regardless of the reason for lack of testing dna ,the fact is its to premature to make any conclusions which leads one to wonder if they might have a agenda. secondly can someone put these numbers into perspective ,how many people died in NYC from eating contaminated shushi since 2006 will the NYC HD ever put out brochure in shushi establishments(i”m not making light of pikuach nefashos,just pointing out that there might be an agenda)

#3, you misinterpreted what the author said. He did not say 100% of Chassidim, he said “(One clear counter-example to the reports findings is the community of Kiryas Joel in Orange County, which has an estimated 100% rate of mbp and 0 reported cases of associated HSV-1.)” He was using a place like Kiyas Yoel as an example, because it’s probable to say the citizens of KJ (all of whom are Satmar Chassidim) most likely use m’tzitzah b’peh. Not so far fetched.

#12, I respectfully urge you to reread the author’s article, peruse the CDC’s report and then have a look at #3’s comment again. The sentence you cite in your comment is entirely irrelevant to the point made in that comment.

#3
Mr Simins, in this article, is stating “A FEW of the weakness in the CDC report”.
Obviously, there are many weaknesses and unsubstantiated conclusions, based on suspicions, assumptions and good old wishful thinking.

Each of us, may have different views and opinions regarding the necessity of Metzizah B’Peh, if performing it by direct oral suction is truly obligatory or is not. However, we ALL must be truthful and honest regarding the facts surrounding the suspected cases.
It is OK for you to be of the opinion that Metzizah B’Peh is not obligatory, buy you are obligated to learn the truth and state only those facts that you know to be true, not what you would like to be true.

Daniel Patrick Moynihan once said that while a person is entitled to his sown opinion, he is not entitled to his own facts. Unfortunately, in order to defend their positions, the deniers postulate their own facts.

#7 Sorry, this time you got it wrong. It is the city that isn’t interested in having a DNA test to link the Mohel to the child. A DNA test would prove just the opposite. It would be established as a definite fact that HSV has nothing to do with mbp. Since the city wants to ban it, it is satisfied with shoddy medical research. It already has the fact, it doesn’t need the evidence to prove it. Proper medical research will only hurt there claims. One thing which I don’t understand is why do you think mohelim want to knowingly infect children? Do you think they want to do mbp if they are spreadin a virus? Any responsible mohel or regular person for that matter would not do something to hurt a child. One of the cases of HSV involved a girl. Does a girl have a Bris? Is mbp done in this case? Did anyone think that maybe the mother who just gave birth and unfortunately broke out with cold sore passed it to the child? Or is it so sure that it has to be mbp that anything pointing to opposite is ignored.

#14, Without a doubt we all need to be truthful, may have an opinion one way or another with respect to chovas MBP if we are legitimate Poskim or, if not, may follow the view of one’s chosen legitimate Posek. However, since here there exists a convergence of halachic practice (with divergent halachic views) with a complex set of facts (statistical and otherwise) that when taken together combine to create at the very least a question of pikuach nefashos (and if deemed significant enough a vast majority, if not all, poskim would prohibit direct oral MBP) it is incumbent upon us to study the data with as much intellectual curiosity and analytical integrity as possible – preconceived notions with respect to the researchers true motives, and lambasting them for those, have no place in this discussion. Further, as professionals (lawyers, statisticians, infectious disease experts, doctors, researchers, other cognoscente, etc.) dig into the details, and are potentially called upon by Rabbonim / Poskim for their professional interpretation based on their expertise, it is vital that they attach the same rigor to their analysis as they would in combing the depths of a Baal Hamoar, Milchemes Hashem or a Pri Megadim.
Many of the points made in Mr. Simins article are salient, but others are not (e.g. based on what we know about our culture and halachic imperatives Kiryas Joel is not a ‘high value’ counter example for no reported herpes in a 100% MBP environment) – our point ought to be to go as deep as possible into the data and make tight, closely thought out, arguments where we find holes in the report, but otherwise take the data and apply halachic principles as we do in other less-charged contexts.

statistics will never prove the facts only a trend by definition. that raises a serious question what has the cdc or nyc hd done as far as investigation as far as i understand the cdc has subpoena power so if they want they can get any mohel to submit to testing ,to knowingly infect someone is a felony the nypd can arrest and get a court order to test as part of discovery process similar to mandatory substance testing. if they were looking for FACTS they sure well can find them and even without testing mohelim, dont you think the cdc if just to get a grip on the situation would at least test the samples on hand to determine if they came from one mohel or maybe more ,no such testing was done WHY?? just headlines!!

#7 Cheek swap cannot be done if the Mohel does not have active sores (you won’t find virus to test).

No practitioner of mbp has been shown to be symptomatic, so those presuming mbp to transmit HSV-1 assume practitioners are shedders. And yet, as the report mentions, attempts to find such shedding in mbp practitioners have failed.

In no case was a mohel found to have active sores so your point is false.

If the standard that you are looking for is absolute proof, you will need to wait a long time until you find a smoking gun to show metzitzah b’peh transmitted herpes. The same can be said about the transmission of a common cold. On the other hand, if you are looking for the preponderance of evidence, then, I believe, the City and other medical journals have presented sufficient data and theory that this practice may be harmful. It is time for those that paskin to take this into account and decide if a minhag whose origin is health related should persist despite our advances in medical theory and practice. I say no, but let it be addressed formally. until now everyone is focusing on the “no proof” argument. That is specious

To SHMUEL
from June 13, 2012 at 9:03 AM,
It is really generous of you to pay for you grand son’s bris.
However, your condition is far from being a ?????. For a couple of dollars any upright ??? will tell you go fly a kite. Our ancestors put their lives on line ????? ???? even to change the color of their shoes, not to mention the way of doing a ???? which might cost them a few dollars.

You are gravely mistaken (or perhaps you are deliberatly stating untrue facts)

The New York City, Dept of Health did in fact administer many such tests to suspected Mohelim, but could not find any DNA of herpes.
They (The NYC dept of health, in their own facilities) administered the standard cheeek, gum, throat, palate swabs and ran a series of PCR tests, but could NOT find any herpes DNA.

These statements are completely true and are known to the all persons involved in his research.

I refer you to the essay by Dr. Berman, posted on Matzav.com, where he concedes that the mohel would not fully cooperate with the investigation, in order to protect his interests. Pray tell, Rabbosai, what does that mean, other than that he was afraid of self-incrimination?

Are those who dispute #7’s comments disputing Dr. Berman’s as well?

How much time had elapsed from the time that the babies contracted HSV-1 and the Health Dept’s seeking DNA? Would not the sore have had time to heal during this time — and there no longer be any shedding of virus?

This does not prove the mohel guilty, but it is a salient fact that is often ignored by those who say that the lack of evidence proves that there is no connection between the mohelim and the infected children.

#18 my point was not about shushi ,but the NYC motives, it is accepted in halocho and in every contemporary society that certain practices including eating shushi where there is no need but for enjoyment never mind something neccesary like construction or driving have inherent risks and and we accept it at a certain threshold (which of course can be argued ad infinitum)My question was if the HD in other contexts DOES accept such risks as part of doing buisness, or won”t get involved due to political risks,and on the other hand is getting involved here due to political pressure I hope i made myself clear